Medical Records (Revised 12-12-19)

MR 1.0 - Medical Records Maintenance, Storage and Handling

Standard: The entity must have policies and procedures in place for proper maintenance, storage and handling of medical records.

Elements of Compliance:

• MR 1.1 The entity must maintain medical imaging records for each patient for at least 5 years or as required by the state. Assessment: Review a sample of records for compliance with date maintenance.

• MR 1.2 The entity must maintain records electronically or physically in a secure, protected area.

• MR 1.3 The entity must have a process for filing and retrieving the medical record.

• MR 1.4 Upon written request from the patient the entity must have a process for transferring images or reports within 2 weeks.

MR 2.0 - Confidentiality of Medical Records

Standard: The entity must ensure confidentiality of medical records.

Elements of Compliance:

• MR 2.1 The entity must have policies and procedures for obtaining information from a patient medical record, in whole or part.

• MR 2.2 The entity must have a process for proper authorization and release of information from the medical record.

• MR 2.3 Original medical records should be released only in accordance with Federal and State laws, court orders or subpoenas.

• MR 2.4 At the time of the examination, the entity must inform patients about how to obtain their images and medical records. Images or reports must be provided in a manner that is useful to the recipient, e.g. media capability of recipient determined.

MR 3.0 - Medical Record Completeness

Standard: The entity creates medical records that are uniform, consistent and complete for each patient.

Elements of Compliance:

• MR 3.1. The medical record should be complete and contain copies of reports, films, scans or other image records.

• MR 3.2 The content and format of patient records are consistent and must include at minimum:

  • Name

  • Identification number

  • Date of birth

  • Gender

  • Responsible party

• MR 3.3 The patient record contains up-to-date information on allergies or material/drug reactions in a prominent and uniform location.

• MR 3.4 Radiology reports contained in the medical record should be signed by the interpreting physician.

Revision History for this Article

Date

Section

Description of Revision(s)

12-12-19

All

Article created; FAQs incorporated; No criteria changes